| Background:To solve the problem of"getting medical care is difficult and expensive",a new round of health care reform was launched by the government in 2009.Using competition to improve the health care supply system is one of the main strategies of this reform.With the implementation of a series of pro-competition policies,the hospital competition degree was intensified.The debate on the effects of hospital competition on medical expenses is fierce.Some researchers believe that the hospital market is similar to the general market in some aspects,so the market competition can play the same role in the hospital market as in the general market.These scholars believe that hospital competition can promote hospitals to improve service efficiency and reduce the supply of unnecessary medical services,thus reducing medical expenses.However,the existence of many particularities in the hospital market,such as serious information asymmetry between physicians and patients,leads to the lack of prerequisites for competition to play a role.Therefore,the theory of market competition in economics cannot be directly applied to the analysis of hospital market competition.Some scholars believe that"market failure"may occur in the hospital market,and hospital competition would bring negative effects,such as"medical arm races",and increase the patients’medical expenses.The effects of hospital competition on medical expenses are associated with the solution to the problem of“getting medical care is expensive”.This study used inpatient expenditure as the analysis object to explore the effects and mechanisms of hospital competition on medical expenses.Based on the theoretical model of“Structure→Behavior→Performance”in industrial economics and the research logic path of“Evaluation→Mechanism→Countermeasure”,this study was carried out from the research process of“key indicators construction,effect evaluation,and mechanism exploration”,and provided the suggestion to improve the policies based on the analysis results.The main research questions are as follows:(1)key indicators construction-how to choose the hospital market definition method and how to construct the measurement of hospital competition?(2)effect evaluation-what is the effect of hospital competition on inpatient expenditure?Is the hospital competition helpful to solve the problem of“getting medical care is expensive”?(3)mechanism exploration-what is the mechanism of hospital competition affecting inpatient expenditure?Through the analysis of the above questions,this study provided suggestions to improve the related policies.This study is based on multi-source(Health Commission,Bureau of statistics,and Gao De map),multi-level(individual,institutional,regional),and spatial-temporal datasets(multi-year data,geographic latitude,and longitude data).Among them,individual data came from the first page of inpatient medical records in Sichuan Province from 2016 to 2019,institutional data came from the annual reports of hospitals in Sichuan Province from 2012 to 2019,and regional data came from Sichuan Statistical Yearbook and Sichuan Health Statistical Yearbook from 2012 to 2020.The geographic latitude and longitude data were obtained from the Gao De map based on the patient’s home address,hospital name,and address.A total of 3,491,387 individual-level observations and 16,086 institutional-level observations were included in the study.Through consistency and correlation evaluation,various hospital market definition methods were compared,including the geopolitical boundaries approach,fixed radius,variable radius,actual patient flow,and predicted patient follow methods.Based on the results,we selected and constructed the suitable hospital definition method and the measurement of hospital competition for this study.This study uses the cross-section fixed effects model,polynomial regression,instrumental variable method combined with the two-stage least squares method,quantile regression,k-means clustering,and clustering algorithm based on density peak combined with Hopkins statistic,contour coefficient,the sum of squares of errors,and Jaccard similarity index to explore the effect of hospital competition on inpatient medical expenses.This study used panel data random effect and fixed effect model combined with multiple limit dependent variable analysis models(LDV),spatial panel model,and seemingly unrelated regression model to explore the mechanism of hospital competition affecting inpatient medical expenses.Part one--The construction of key indicators:Systematically comparing the five commonly used hospital market definition methods and the measurements of competitive degree,and constructing the indicators of this study based on the analysis results.Methods:The inpatient medical records of all patients in Sichuan Province in the fourth quarter of each year from 2016 to 2019 were collected.Based on ICD-10,the first 50%of inpatient numbers and expenditure of a single disease were selected as the analysis objects of this study.The study also collected hospital data from the annual report data of all hospitals in Sichuan Province from 2016 to 2019.The geographic longitude and latitude information was obtained from the Gaode map.This study systematically discussed a series of hospital market definition methods and the measurements of hospital competition and summarized their advantages,disadvantages,and applicability from the qualitative perspective.In addition,the consistency histogram and correlation coefficient matrix were used to evaluate the consistency and correlation of the measurement of hospital competition based on different hospital market definition methods.The hospital market definition methods compared in this part include the geopolitical boundaries approach,fixed radius,variable radius,actual patient flow,and predicted patient follow methods.The measurement of hospital competition mainly focuses on the Herfindahl-Hirschman Index(HHI).Results:The distribution of HHIs based on different hospital market definition methods is overlap to a certain degree.The degree of overlap of distribution of HHI calculated by fixed radius and precited patient flow is greater than other traditional definition methods,suggesting the fixed radius and precited patient flow approach is more consistent.The correlation coefficients between HHIs calculated by different hospital market definition methods are statistically significantly greater than 0,which shows that the market competition intensity measured based on different hospital market definition methods is significantly positively correlated.Compared with other traditional hospital market definition methods,the HHI correlation coefficient based on the fixed radius method and predicted patient flow method is greater.Conclusion:Although different hospital market definition methods are based on different principles,the hospital competition degree measured by different hospital market definition methods is not completely different.Comparing the traditional hospital market definition method with the predicted patient flow method,this study found that the hospital competition measured by the fixed radius method is more similar to that measured by the predicted patient flow method.Based on the results of this part,combined with the research problems and data conditions of each part of this study,the predictive patient flow method and the fixed radius method are used as the hospital market definition methods and then measured the hospital competition in the subsequent empirical analysis of this study.Part two--effect evaluation:Evaluating the effect of hospital competition on inpatient expenditure,and exploring whether hospital competition can help to solve the problem of“getting medical care is expensive”.Methods:The individual and institutional level data were consistent with the part of the construction of key indicators.The regional data and longitude and latitude were collected from Sichuan statistical yearbook and Sichuan health statistical yearbook,as well as the Gao De map respectively.This study used the predictive patient flow method combined with HHI to define the hospital market and measure the hospital competition degree,and the logarithmic linear fixed effect model was used as the main regression model.We also employed the instrumental variable method combined with the two-stage least square method further to control the potential endogenous problems.Polynomial regression was used to explore the nonlinear impact of hospital competition.To fully understand the effect of hospital competition on inpatient expenditure,this part also explored the heterogeneity of the effect of hospital competition from many aspects,including inpatient expenditure under different quantiles,different medical insurance types and hospital types,subgroup inpatient expenditure,regional demander scale,primary health care development level,and the extent of information symmetry degrees.Results:After controlling a series of confounders,the estimated coefficient of HHI is 0.121 and statistically significant at the test level of 5%.The results show that when HHI decreased by one standard deviation(0.113),the inpatient expenditures average decreased by 1.4%,suggesting that the greater the competition intensity,the smaller the inpatient expenditures.The regression results of the instrumental variable method combined with the two-stage least square method show that the estimation coefficient of the fitted value of endogenous variables is 0.241 with statistically significant,which verifies the results of the main regression.Adding the HHI~2 in the main regression model,the estimated results show that the estimated coefficient of HHI~2 and HHI are-0.039 and 0.145 respectively,and both are statistically significant.Combined with the value range of HHI,it is determined that for all the values of HHI,the smaller the HHI,the smaller the expenditures of inpatients,suggesting that the greater the competition intensity,the smaller the expenditures of inpatients.The study also found that hospital competition had a variety of heterogeneous effects on inpatient medical expenses,including different quantile inpatient medical expenses,medical insurance types,hospital characteristics,subgroup inpatient medical expenses,regional demanders’scale,primary health care development level,and the extent of information asymmetry between physicians and patients.Conclusion:(1)the increase in hospital competition intensity can reduce inpatient medical expenses,indicating that hospital competition can help to reduce patients’economic burden and solve the problem of“getting medical care is expensive”.(2)even for hospitals located in highly competitive market,the improvement of hospital competition can still reduce the inpatient expenditures;(3)the higher the inpatient expenditures,the greater the effects of hospital competition to reduce the expenditures;(4)compared with the UEBMI,the effect of hospital competition to reduce the inpatient expenditures is greater for patient with URBMI,NRCMS,and self-pay;(5)compared with non-profit,public,and tertiary hospitals,hospital competition has greater effects on the reduction of inpatient expenditures in profit hospitals,private hospitals,and low-level hospitals;(6)the effects of hospital competition on the different subgroups inpatient expenditures are as follows:inpatient consumable expenditures>inpatient diagnosis expenditures>inpatient drug expenditures>inpatient service expenditures,while for inpatient treatment expenditures,the greater the intensity of hospital competition,the higher the inpatient treatment expenditures;(7)the effect of hospital competition on reducing inpatient expenditures is affected by the scale of demanders.With the increase of the scale of demanders,the effect of hospital competition on reducing inpatient expenditures also increases;(8)the higher the level of primary health serviceability,the greater the effect of hospital competition on reducing inpatient expenditures.The development of primary health services would have a“spillover effect”on the exertion of hospital competition effect;(9)the degree of information asymmetry between physicians and patients would hinder the effect of hospital competition on reducing inpatient expenditures.The greater the information gap between physicians and patients,the weaker the effect of hospital competition on reducing inpatient expenditures.Part three--mechanism analysis:Analyzing the mechanism of hospital competition affecting inpatient medical expenses.This part consists of two parts:the determination of mediating variable and the estimation of mediating effects.Firstly,based on the SCP theoretical model,we took the hospital conduct as the potential mechanism source set of hospital competition affecting inpatient expenditure and analyzed the effect of hospital competition on hospital conduct to determine the mediating variable.Secondly,this study estimated the mediating effects of hospital conduct on the influence of hospital competition on inpatient medical expenses.Methods:Institutional-and regional-level data is collected from the annual report data of all hospitals in Sichuan Province from 2012 to 2019 and the Sichuan statistical yearbook and Sichuan health statistical yearbook.Geographic longitude and latitude information data were obtained from the Gao De map based on hospital name and address information using open API.First,this study defined two types of hospital conduct as the potential mechanisms to be explored,including medical technology investment behavior and service efficiency adjustment conduct.The number of medical devices with single costs exceeding 1000,000 Yuan is used as the proxy variable of medical technical investment of the hospital,and the hospital bed turnover times as the proxy variable of hospital medical service efficiency.Using a series of analysis strategies of panel data,including random effect and fixed effect models,combined with the limited dependent variable(LDV)analysis model,including the Poisson regression model,Negative Binomial regression model,and Tobit regression model,this study explored the effect of hospital competition on hospital conducts.The study also used the spatial panel model to control the potential impact of spatial effects and further verified the analysis results.Second,based on the definition and identification principle of mediating effect,a seemingly unrelated regression model was constructed and combined with the Bootstrap nonparametric sampling method to estimate the mediating effects of hospital conduct.Results:In the regression model for medical technology investment behavior,after controlling a series of confounders,the estimate of HHI is-0.885 with statistically significant.The results show that when HHI decreased by 10%,the number of medical devices with single costs exceeding 1000,000 Yuan increased by 8.85%on average.In the regression model for service efficiency adjustment conduct,after controlling a series of confounders,the estimate of HHI is-0.673 with statistical significance.The results show that when HHI decreased by 10%,the hospital bed turnover times increased by an average of 6.73%.In the seemingly unrelated regression equations,the mediating effect of technology investment is-0.070,and its’95%confidence interval calculated by the bootstrap nonparametric sampling method is(-0.092,-0.047),and the proportion of this mediating effect in the total effect is-45.161%.The results suggest that hospital competition increases the inpatient expenditures of hospitals by increasing hospital medical technology investment.The existence of this mediating effect would weaken the effect of hospital competition to reduce inpatient expenditures.The mediating effect of hospital medical service efficiency is 0.075,and its’95%confidence interval calculated by the bootstrap nonparametric sampling method is(0.049,0.100),and the proportion of this mediating effect in the total effect is 48.387%.The results show that hospital competition would reduce the average inpatient expenditures of hospitals by improving the medical service efficiency of hospitals,suggesting that one of the ways for hospitals to reduce inpatient expenditures is to improve the medical service efficiency.Conclusion:(1)Hospital competition increases the medical expenses of inpatients by promoting hospitals to invest in more advanced medical technology.(2)Hospital competition reduces the medical expenses of inpatients by improving the service efficiency of hospitals.That is,one of the mechanisms of hospital competition to reduce the medical expenses of inpatients is to improve the medical service efficiency,but the advanced medical technology investment conduct would weaken the effect of hospital competition in reducing inpatient medical expenses.Research summary:It is important to clarify the effects of hospital competition on inpatient medical expenses for solving the problem of“getting medical care is expensive”.This study found that hospital competition can play a role in reducing inpatient medical expenses,and help to reduce patients’economic burden,solving the challenge of“getting medical care is expensive”.The study also found that one of the mechanisms of hospital competition to reduce the medical expenses of inpatients is to improve service efficiency,but the medical technology investment caused by competition would weaken these effects.Based on the findings of this study,we concluded that the pro-competition policies should continue to be implemented rather than stopped.In addition,only relying on market forces cannot give full play to the effect of hospital competition on reducing medical expenses.It is necessary for the government to take measures to avoid or control the potential negative effects of competition and give full play to the effect of hospital competition in reducing medical expenses. |
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